Hey Reader, Dr Karl here.

Four years of work. Here is what moved.
Fasting insulin 9.6 to 3.4. Fasting glucose 108 to 92. CRP 3.6 to 0.47. HOMA-IR 2.6 to 0.8. Thirty-five pounds over ideal body weight down to twenty-four. No medication for any of it.

And her hemoglobin A1c went from 5.3 to 5.7.

Up! In the wrong direction. And 5.7 is not a neutral number. It is the exact line where the American Diabetes Association says prediabetes begins. Four years of doing everything right and the one marker her doctor is most likely to look at moved her across a diagnostic boundary.

If you only had that number, the story writes itself. She is heading for diabetes. Start metformin. Cut the fat, cut the meat, eat more whole grains.

Every part of that would have been wrong.

Here is how I know. She wore a continuous glucose monitor. Not for a day, for weeks, across the period. Her trace is flat. Low, steady, barely moving through the day. Four years ago it was jagged, and now it is what I have called flat and boring since before anyone was selling these things.
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A1c is supposed to be a summary of your average glucose over roughly three months. So when the A1c says one thing and fourteen days of five-minute glucose readings say the opposite, one of them is lying.

It is not the CGM.

A single lab value is not a finding. It is a rumor. It becomes a finding when other things point the same way, and in her case everything else points away from the A1c: the insulin, the glucose, the inflammation, the weight, the monitor. One turtle on a fence post is a question. Her A1c is one turtle, on its own, arguing with five other markers.

So the question is not whether she is becoming diabetic. She isn't. The question is why a test built to measure average glucose stopped tracking her average glucose.

I know the answer. It is not a dodge and it is not exotic, and it is sitting in her red cell counts where nobody looks.

That is the next email.

To your health,

Dr. Goldkamp

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